Consequences of Inadequate Supervision

FIG U RE 8.4 Systems perspective model of accident causation in complex systems. (Adapted from Reason, J., British Medical Journal, 320, 768-770, 2000.) 

Inadequate Supervision Failure to provide proper training Failure to provide professional guidance or oversight Failure to provide current publications, adequate technical data, or procedures Failure to provide adequate rest period Lack of accountability Perceived lack of authority Failure to track qualifications Failure to track performance Failure to provide operational doctrine Overtasked or untrained supervisor Loss of supervisory situational awareness 

Planned Inappropriate Operations Poor crew pairing 

Failed to provide adequate brief time or supervision Benefit outweighed by risk 

Failure to provide adequate opportunity for crew rest Excessive tasking or workload 

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